Identifying Facilitators and Barriers to Increasing COVID-19 Vaccination and Trial Participation in Vaccinated Vietnamese Americans

Background: Preventing morbidity and mortality from COVID-19 requires reaching diverse communities. Purpose: To identify facilitators and barriers to COVID-19 immunization and COVID-19 clinical trial participation in the vaccinated Vietnamese American population in Houston, TX. Methods: Community-based qualitative study using focus groups and key informant interviews. Results: Themes that emerged included culturally appropriate language, generational differences, and a collectivist approach. Conclusion: Promoting science-based information through trusted messengers, improving awareness and access, and illuminating benefits to the community could increase the uptake of COVID-19 vaccines and volunteering for therapeutic trials among Vietnamese Americans.


Introduction
In the United States, the COVID-19 pandemic disproportionately impacted people of color, including Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI). While the AANHPI COVID-19 death rate is lower than its population share, the overall data were less commonly reported, AANHPI are often classified as ''other,'' and data usually are not disaggregated, underestimating disparities in and within the AANHPI population. 1,2 In some areas that reported disaggregated data, Vietnamese Americans were overrepresented in coronavirus cases. 3,4 To prevent severe illness and deaths from COVID-19, it is essential to reach diverse communities to raise awareness about measures such as COVID-19 vaccination and participation in clinical therapeutic trials. Some surveys have found that AANHPI are willing to receive COVID-19 vaccines, but they may have limited survey language accessibility, did not disaggregate data, or did not investigate specific reasons. 5,6 Flores et al. found that 34% of vaccine trials from 2011 to 2020 reported ethnicity and did not disaggregate AANHPI data beyond Hawaiian, Pacific Islander, and Alaska Native. 7 Our purpose was to identify facilitators and barriers to COVID-19 immunization and clinical trial participation in the Vietnamese American population.

Materials and Methods
We conducted focus groups and key informant interviews between August to October 2021 using a community-engaged approach. Boat People SOS Houston (BPSOSH) used a convenience sampling strategy to recruit Vietnamese American adults in the Houston area who could choose English or Vietnamese for the survey, focus groups, and interviews. For key informant  Tables 1 and 2. Focus group participants completed an online prefocus group survey that evaluated demographic information, access to care, vaccination status, COVID-19 risk, and clinical trial experiences. Each focus group lasted between 60 and 90 min via teleconference. Key informant interviews lasted between 40 and 75 min and were conducted in person or via teleconference. As an incentive, we offered a $50 gift card to all participants. This research was approved by the University of Houston IRB.

Data analysis
Data analysis followed a thematic analysis approach. After each focus group or interview, C.N., L.G., and J.D. debriefed, reviewed the notes, and listened to the audio recording. Transcripts of English sessions and detailed notes of Vietnamese sessions were created and adjusted to accurately capture the conversations. C.N. and L.G. independently coded each session, using an inductive coding approach to derive preliminary codes directly from the data to reflect the participants' experiences. Analysis of data was ongoing, and C.N., L.G., and B.M.N. met regularly to discuss emerging codes and themes. Through this iterative group approach, a final set of codes and themes were collectively agreed upon by the research team using NVivo. These findings were then validated and refined based on feedback by the community partners BPSOSH and PIVOT. The resulting themes are representative of the repeated patterns of meanings throughout the interviews and focus groups.

Results
In total, 20 adults participated in 4 focus groups with half held in Vietnamese. The sociodemographic   characteristics of the focus group participants can be found in Table 3, while Table 4 provides information regarding participants' vaccination status and perceptions. For key informant interviews, two faith leaders, two health care workers, and one small business owner participated with three out of five interviews in Vietnamese. Table 5 presents the overall thematic analysis, including major themes, subthemes, and salient quotes from participants. Figure 1 displays how the themes intersect.

Language
Participants reported limited availability of COVID-19 information in Vietnamese. They emphasized the im-portance of cultural competence and quality in translations to relay accurate information. In addition, well-translated health information in Vietnamese or a Vietnamese health care provider increases their trust in medicine. Participants also discussed how lack of translated materials likely prevents engagement with clinical trials.

Generational differences
Many participants reported generational differences related to COVID-19 misinformation and trusted sources of information. Some individuals reported that language barriers impact older Vietnamese people's access to credible COVID-19 and vaccination information.
In addition, younger participants reported cultural influences such as significance of familial hierarchy and respecting elders affecting discussions on COVID-19 misinformation.
Collectivist approach and perspective A collectivist perspective also played a role in receiving the vaccine or participating in clinical trials in the Vietnamese community. Participants identified the importance of increasing vaccination rates in the community to decrease COVID-19 infections and increase community safety as a facilitator of obtaining the vaccine.
To increase clinical trial participation, individuals consistently stressed the potential of clinical trials to help the community.

Facilitators for vaccines
Participants identified several facilitators to getting vaccinated. Many participants reported that the fear of severe illness or death from COVID-19 influenced their decision to get vaccinated. Many participants highlighted ease of access to get vaccinated in their communities. Other participants recognized the privilege in vaccine access in the United States compared with Vietnam. Overall, participants trusted the science behind the vaccine. They also revealed that their most trusted sources of information were medical professionals (especially of Vietnamese descent), faith-based organizations, and the government. Most participants conducted a cost-benefit analysis, and ultimately believed that the vaccine benefits outweighed the risks.

Barriers for vaccines
Although all participants had received at least one dose of a vaccine, they still identified potential barriers. At the beginning of the pandemic, participants recalled inequalities in initial vaccine distribution, long wait times at vaccination centers, and initial fears related to misinformation about the efficacy and safety. Participants shared concerns that the vaccine would cause side effects or worsen their existing medical conditions. In addition, one participant reported a stigma of being vaccinated in their community.

Clinical trials
Participants reported barriers that prevented clinical trial participation in their community: lack of trust in the government, time, and knowledge about clinical trials. Other participants suggested facilitators to increase interest and participation, such as increasing trust and awareness, and financial incentives. However, some participants did not believe any efforts would increase clinical trial participation due to cultural unfamiliarity.

Discussion
A few overarching themes influencing participants' decision-making around COVID-19 vaccination and clinical trial participation emerged: language, generational differences, and a collectivist approach. Previous research has found a similar impact of collectivism to encourage optimal COVID-19 mitigation behavior. 8 In studying Vietnamese Americans' willingness to vaccinate against COVID-19, risk of severe illness, ease of access, trust in science, and having trusted sources of information in culturally translated Vietnamese also arose as important facilitators. These facilitators of vaccination were also identified in studies focused on AANHPI populations. 9 Participants reported barriers to vaccines such as concerns about vaccine safety, misinformation, and  10 Prior research demonstrated that AANHPI with limited English proficiency (LEP) were more likely to have unmet health care needs and communication problems in health care settings. 11,12 Among the largest AANHPI groups in the United States, Vietnamese Americans have one of the highest rates of LEP with 48% of adults. 13 Participants' concerns about trusted sources of information in Vietnamese echo challenges with misinformation in the Vietnamese community as well as other AANHPI populations. 14,15 Our findings of uneasiness regarding language access to scientific evidence and importance of information dissemination through trusted messengers are consistent with prior qualitative research on COVID-19 vaccine acceptability in other populations. 10,16 Apprehensions around clinical trial participation included lack of trust in the government, time, and knowledge and are similar to previous research on AANHPI populations. 17 To increase therapeutic trial involvement, participants suggested underscoring the benefit of research on the community, raising awareness in Vietnamese, and providing monetary compensation. This is consistent with previous research that found focusing on altruistic messages from a physician of the same nationality and/or spoke the same language may motivate clinical trial participation in AANHPI. 18 However, offering payment to research volunteers is a contentious practice. 19 Our study is the first to examine Vietnamese Americans' perceptions of COVID-19 vaccination and clinical therapeutic trial participation. These findings can help public health departments and communitybased organizations working with this population develop effective messages. However, this study contains limitations. The focus groups were held virtually so they did not include people with unreliable internet access. The sample size was small and did not contain unvaccinated individuals or folks living in rural areas due to limited funding and capacity. The few unvaccinated individuals recruited were unable to attend the focus groups. These results may not be replicable or generalizable. Nevertheless, the lack of COVID-19-specific studies involving and about Vietnamese Americans makes this a valuable contribution to the literature.

Conclusion
In brief, culturally appropriate language, generational differences, and a collectivist approach were important themes impacting COVID-19 immunization and clinical trial participation in this Vietnamese American population. Promoting science-based information through trusted messengers, improving awareness and access, and illuminating benefits to the community may increase the uptake of COVID-19 vaccines and volunteering for therapeutic trials. These recommendations can help government agencies, health care providers, and community organizations working with Vietnamese American communities advance public health.
A potential next step is to survey a larger population of Vietnamese Americans to see if these results are replicable and to focus on COVID-19 vaccine facilitators and barriers among the unvaccinated Vietnamese American population. Based on comments from these participants, future COVID-19 research in Vietnamese Americans could explore mental health and the impact of rise in AANHPI hate crimes. Our community partners noted difficulties in recruiting unvaccinated individuals due to the need for separate focus groups to create a thoughtful permissive atmosphere. They also highlighted the slow uptake of COVID-19 vaccinations in children and boosters in adults along with difficulties in reaching rural, unhoused, or technologically limited populations.